Prevalence of dry eye is reported to be up to 20 per cent in non-contact lens wearers1,2 and about 50 per cent3-5 in contact lens wearers. Discomfort and dryness during wear appear to be the major causes of contact lens wear discontinuation.6 Approximately 50 per cent of patients who drop out from contact lens wear in the UK, and 75 per cent in the US, do so because of discomfort related to lens wear.7 Additionally, dry eye negatively impacts on quality of life,8 and also reduces vision quality.9 Bearing this in mind, dry eye management is an important part of eye care practice, for both optometrists and dispensing opticians.
Management options
Many different management options are available; eye drops, eye gels, eye sprays, eye bags, lid hygiene measures, lid ‘scrubs’, punctum plugs and medications. However, the main question is, which one is best for my patient? For contact lens wearers, the nature of their lens influences symptoms and also there is a need to address any contributory or co-existing pathology.10 So perhaps the questions should be:
? Is this patient a dry eye patient?
? If yes, what is the dry eye type of this patient?
Only after considering these can an appropriate treatment be recommended to improve dry eye symptoms and correlating ocular signs. However, dry eye tests are different in their sensitivity and specificity and using a combination of different dry eye tests and questionnaires appears to improve diagnoses.11,12 Unfortunately there is no consensus among practitioners which test(s) to use.13-16 Even though optometrists use subjective and objective evaluation and stratify treatment based on dry eye severity, there is a lack of uniformity regarding diagnostic testing, use of standardised grading scales, and significant variability in clinical care.15 These findings highlight the potential to improve the translation of dry eye research evidence and evidence-based guidelines into practice.15
PULT-test
Based on several studies, a computer-based software system (the PULT-test, winner of the 2009 Peter Abel Award17) was launched in 2009 to predict contact lens-related dry eye in naive and experienced contact lens wearers. This has been used successfully in Germany, Switzerland and Austria, but recent clinician feedback has highlighted the need for an additional evidence-based scheme to differentiate between dry eye types and to give appropriate treatment recommendations. Additionally, dispensing opticians without access to a slit-lamp microscope have asked for a tool based on validated questionnaires. Furthermore, a tablet-based application is more useful in the modern clinic. Consequently, further research was conducted and an iPad app was developed, named the Dry Eye Tool Box.
Dry Eye Tool Box
The Dry Eye Tool Box is a professional app aiming to improve dry eye management, to decrease dropout rate in contact lens wearers and such to improve patients’ satisfaction, loyalty and compliance. This app consists of three modules (Figure 1):
[CaptionComponent="290"]? Dry Eye Screening – predicts dry eye in non-contact lens wearers, naive contact lens wearers and experienced lens wearers
? Dry Eye Management – diagnoses dry eye type and offers appropriate treatment and contact lens recommendations
? Symptometer – a validated questionnaire for non-contact lens wearers (Ocular Surface Disease Index)18,19 and another for contact lens wearers.20
The screening section is a questionnaire and also requires at least one objective tear film and one ocular surface test. Details of the tests may be accessed by clicking on them (Figure 2).
[CaptionComponent="291"]The likelihood of dry eye and dry eye type for the three patient groups will be calculated using algorithms evaluated in the literature (Figure 3).11,20-22
[CaptionComponent="292"]The management section (Figures 4 and 5), after completion, suggests appropriate treatment options again based on the latest literature.23,24
[CaptionComponent="293"][CaptionComponent="294"]
For contact lens wearers the risk of co-existing dry eye may be evaluated (Figure 6).
[CaptionComponent="295"]Evidence-based recommendations for improved contact lens wearing comfort are offered, grouped by contact lens design, material, wearing regime and care system.10 The Symptometer (Figure 7) might be used by auxiliary staff, either as a quick screening or to monitor the impact of any intervention recommended by the clinician.
This app was tested in clinical practice over a period of almost one year and included feedback garnered from 30 well known dry eye experts before final launch. Beside the benefit of a tool helping to diagnose dry eye and contact lens wearing discomfort with high sensitivity and specificity it was rated to be very easy to use, very patient friendly and time exposure was surprisingly short. It is hoped the Tool Box will prove a useful and effective way of helping those with dry eye symptoms.
[CaptionComponent="296"]References
1 Johnson ME, Murphy PJ. Measurement of ocular surface irritation on a linear interval scale with the ocular comfort index. Invest Ophthalmol Vis Sci, 2007;48:4451-8.
2 Smith JA, Albeitz J, Begley C, Caffery B, Nichols K, Schaumberg D, Schein O. The epidemiology of dry eye disease: Report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf, 2007;5:93-107.
3 Nichols JJ, Mitchell GL, Nichols KK, Chalmers R, Begley C. The performance of the contact lens dry eye questionnaire as a screening survey for contact lens-related dry eye. Cornea, 2002;21:469-75.
4 Begley CG, Caffery B, Nichols KK, Chalmers R. Responses of contact lens wearers to a dry eye survey. Optom Vis Sci, 2000;77:40-6.
5 Nichols JJ, Sinnott LT. Tear film, contact lens, and patient-related factors associated with contact lens-related dry eye. Invest Ophthalmol Vis Sci, 2011;47:1319-28.
6 Richdale K, Sinnott L, Skadahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea, 2007;26(2):168-74.
7 Pritchard N. How can we avoid CL drop-outs? Optician, 2001;5825:222:14-8.
8 Friedman NJ. Impact of dry eye disease and treatment on quality of life. Curr Opin Ophthalmol, 2010;21:310-6.
9 Montes-Mico R. Role of the tear film in the optical quality of the human eye. J Cataract Refract Surg, 2007;33:1631-5.
10 Papas EB, Ciolino JB, Jacobs D, et al, members of the TIWoCLD. The TFOS International Workshop on Contact Lens Discomfort: Report of the Management and Therapy Subcommittee. Invest Ophthalmol Vis Sci, 2013;54:TFOS183-203.
11 Pult H, Bandlitz S. Leitfaden Trockenes Auge. Der Augenoptiker 2012;10:71-3.
12 2007 report of the international dry eye workshop (DEWS). Ocul Surf, 2007;Volume 5.
13 Graham JE, McGilligan VE, Berrar D, et al. Attitudes towards diagnostic tests and therapies for dry eye disease. Ophthalmic Res, 2010;43:11-7.
14 Turner AW, Layton CJ, Bron AJ. Survey of eye practitioners’ attitudes towards diagnostic tests and therapies for dry eye disease. Clin Experiment Ophthalmol, 2005;33:351-5.
15 Downie LE, Keller PR, Vingrys AJ. An evidence-based analysis of Australian optometrists’ dry eye practices. Optom Vis Sci, 2013;90:1385-95.
16 Tilia D, Lazon de la Jara P, Peng N, et al. Effect of Lens and Solution Choice on the Comfort of Contact Lens Wearers. Optom Vis Sci, 2013.
17 Pult H. Die Vorhersagewahrscheinlichkeit klinischer Tests zum trockenem Auge beim Kontaktlinsentragen. Die Kontaktlinse, 2009;10:1-9.
18 Schiffman RM, Christianson MD, Jacobsen G, et al. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol, 2000;118:615-21.
19 Dougherty BE, Nichols JJ, Nichols KK. Rasch analysis of the Ocular Surface Disease Index (OSDI). Invest Ophthalmol Vis Sci, 2011;52:8630-5.
20 Pult H, Purslow C, Murphy PJ. CLIDE-Index: A novel method to diagnose and measure Contact Lens Induced Dry Eye (CLIDE)? In: 107. DOG Kongress. Leipzig, Germany; 2009.
21 Pult H, Murphy PJ, Purslow C. A Novel Method to Predict Dry Eye Symptoms in New Contact Lens Wearers. Optom Vis Sci, 2009;86:E1042-50.
22 Pult H, Purslow C, Berry M, Murphy PJ. Clinical tests for successful contact lens wear: relationship and predictive potential. Optom Vis Sci, 2008;85:E924-9.
23 Geerling G, Tauber J, Baudouin C, et al. The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci, 2011;52:2050-64.
24 Pflugfelder SC, Geerling G, Kinoshita S, et al. Management and therapy of dry eye disease: report of the management and therapy subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf, 2007;5:163-78.
Dr Heiko Pult has a research practice in Weinheim, Germany and is honorary research fellow at Cardiff University (www.dry-eye-tool-box.com)